Eran Bendavid, MD; Jayanta Bhattacharya, MD, PhD
Acknowledgment: The authors thank Karen Stanecki of UNAIDS for help with providing and clarifying the data used in this study and Grant Miller, PhD, and Kanaka Shetty, MD, MS, of the Center for Health Policy at Stanford University for methodologic contributions.
Grant Support: By a training grant from the Agency for Healthcare Research and Quality (Dr. Bendavid) and the National Institute on Aging (Dr. Bhattacharya).
Potential Financial Conflicts of Interest: None disclosed.
Reproducible Research Statement:Study protocol: Not available. Statistical code: Available from Dr. Bendavid (e-mail, firstname.lastname@example.org). Data set: The HIV epidemiologic data are available from UNAIDS (www.unaids.org). The complete data set is available from Dr. Bendavid (e-mail, email@example.com).
Requests for Single Reprints: Eran Bendavid, MD, 117 Encina Commons, Stanford, CA 94305; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Bendavid and Bhattacharya: 117 Encina Commons, Stanford, CA 94305.
Author Contributions: Conception and design: E. Bendavid, J. Bhattacharya.
Analysis and interpretation of the data: E. Bendavid, J. Bhattacharya.
Drafting of the article: E. Bendavid, J. Bhattacharya.
Critical revision of the article for important intellectual content: E. Bendavid, J. Bhattacharya.
Final approval of the article: E. Bendavid, J. Bhattacharya.
Statistical expertise: E. Bendavid, J. Bhattacharya.
Administrative, technical, or logistic support: J. Bhattacharya.
Collection and assembly of data: E. Bendavid, J. Bhattacharya.
Since 2003, the President's Emergency Plan for AIDS Relief (PEPFAR) has been the most ambitious initiative to address the global HIV epidemic. However, the effect of PEPFAR on HIV-related outcomes is unknown.
To assess the effect of PEPFAR on HIV-related deaths, the number of people living with HIV, and HIV prevalence in sub-Saharan Africa.
Comparison of trends before and after the initiation of PEPFAR's activities.
12 African focus countries and 29 control countries with a generalized HIV epidemic from 1997 to 2007 (451 country-year observations).
A 5-year, $15 billion program for HIV treatment, prevention, and care that started in late 2003.
HIV-related deaths, the number of people living with HIV, and HIV prevalence.
Between 2004 and 2007, the difference in the annual change in the number of HIV-related deaths was 10.5% lower in the focus countries than in the control countries (P = 0.001). The difference in trends between the groups before 2003 was not significant. The annual growth in the number of people living with HIV was 3.7% slower in the focus countries than in the control countries from 1997 to 2002 (P = 0.05), but during PEPFAR's activities, the difference was no longer significant. The difference in the change in HIV prevalence did not significantly differ throughout the study period. These estimates were stable after sensitivity analysis.
The selection of the focus countries was not random, which limits the generalizability of the results.
After 4 years of PEPFAR activity, HIV-related deaths decreased in sub-Saharan African focus countries compared with control countries, but trends in adult prevalence did not differ. Assessment of epidemiologic effectiveness should be part of PEPFAR's evaluation programs.
Agency for Healthcare Research and Quality.
The effects of the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) are unknown.
Using data obtained from the United Nations, the authors detected a decrease in the number of HIV-related deaths in African countries receiving U.S. assistance after PEPFAR was introduced.
Many factors other than introduction of PEPFAR could have contributed to the observed findings.
The PEPFAR program seems to be having some favorable effects in African countries receiving AIDS assistance.
Table 1. Focus and Control Countries
Table 2. Demographic Characteristics and Baseline HIV Epidemic Estimates
Longitudinal epidemic trends of the study outcomes.
Data are presented as means (95% CIs).
Table 3. Differences in Outcomes Between the Focus and Control Countries During the Early and Late Study Periods
Differences in outcomes between focus and control countries over time.
Each data point represents the difference in the percentage change from the previous year to the current. That is, each point represents (Xt − Xt−1/Xt−1)focus − (Xt − Xt−1/Xt−1)control for outcome X in year t. Negative numbers mean that the outcome decreased faster (or increased more slowly) in the focus countries. Deflections away from zero suggest that the differences became more pronounced, whereas deflections toward zero mean that the trends were becoming more similar. The dotted lines represent the transition period around 2003, when the President's Emergency Plan for AIDS Relief was being organized.
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Bendavid E, Bhattacharya J. The President's Emergency Plan for AIDS Relief in Africa: An Evaluation of Outcomes. Ann Intern Med. 2009;150:688–695. doi: 10.7326/0003-4819-150-10-200905190-00117
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Published: Ann Intern Med. 2009;150(10):688-695.
HIV, Infectious Disease.
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